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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. `` Job Address / �76 (JOA� ,<05AC'Y City �r ` Lot Size PM Owner's Name /4"C' Phone Contractor 4& 7-0 ZWW. Address O �?icense No.5 � one !�� X h TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT .CIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca . . ll Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications M-1 Public ❑ Othe (-1 Delta Depth of Grout Seal Type of Grout I i Irrigation rox. Depth l I Eastern Surface Seal Installed by Repair Work Done ype of Pump + H.P. State Work Done Well Dest n ❑ Well Diameter Sealing Material (top 50') QQ Depth Filler Material (Below 501 _ J TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Resi nce X Commercial— Other Number of living units: Number of bedrooms d Character of soil to a dept of 3 feet: ZZ� Water table depth -- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line O LEACHING LINE No. & Length of lines Total len e 9 FILTER BED ❑ Distance to nears :PNVO6Well Foundation "Ill`__ Property tine SEEPAGE PITS l I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in spch manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant us 11 for al quired i pections. drawing on r verse side. fG] Signed X Title: r Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Date .- Area Pit or Grout Inspectio Date Final Inspection by Date 3 U + Additional Comments: ` re vef ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Man eco 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE CK A INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE CPERMIT NO. 14 EH 14-2s EH -24IAEv,riHsl f a r 2